﻿<?xml version="1.0" encoding="utf-8" ?>
<TransactionSpecification xmlns="http://tempuri.org/X12ParserSpecification.xsd" TransactionSetIdentifierCode="834">
  <Segment SegmentId="BGN"/>
  <Segment SegmentId="REF"/>
  <Segment SegmentId="DTP"/>
  <Loop LoopId="1000A">
    <Name>SPONSOR NAME</Name>
    <StartingSegment  SegmentId="N1">
      <EntityIdentifier Code="P5"/>
    </StartingSegment>
  </Loop>
  <Loop LoopId="1000B">
    <Name>PAYER</Name>
    <StartingSegment SegmentId="N1">
      <EntityIdentifier Code="IN"/>
    </StartingSegment>
  </Loop>
  <Loop LoopId="1000C">
    <Name>TPA/BROKER NAME</Name>
    <StartingSegment SegmentId="N1">
      <EntityIdentifier Code="BO"/>
      <EntityIdentifier Code="TV"/>
    </StartingSegment>
    <Loop LoopId="1100C">
      <Name>TPA/BROKER ACCOUNT INFORMATION</Name>
      <StartingSegment SegmentId="ACT"/>
    </Loop>
  </Loop>
  <Loop LoopId="2000">
    <Name>MEMBER LEVEL DETAIL</Name>
    <StartingSegment SegmentId="INS"/>
    <Segment SegmentId="REF"/>
    <Segment SegmentId="DTP"/>
    <Loop LoopId="2100A">
      <Name>MEMBER NAME</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="74"/>
        <EntityIdentifier Code="IL"/>
      </StartingSegment>
      <Segment SegmentId="PER"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
      <Segment SegmentId="DMG"/>
      <Segment SegmentId="ICM"/>
      <Segment SegmentId="AMT"/>
      <Segment SegmentId="HLH"/>
      <Segment SegmentId="LUI"/>
    </Loop>
    <Loop LoopId="2100B">
      <Name>INCORRECT MEMBER NAME</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="70"/>
      </StartingSegment>
      <Segment SegmentId="DMG"/>
    </Loop>
    <Loop LoopId="2100C">
      <Name>MEMBER MAILING ADDRESS</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="31"/>
      </StartingSegment>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
    </Loop>
    <Loop LoopId="2100D">
      <Name>MEMBER EMPLOYER</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="ES"/>
      </StartingSegment>
      <Segment SegmentId="PER"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
    </Loop>
    <Loop LoopId="2100E">
      <Name>MEMBER SCHOOL</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="M8"/>
      </StartingSegment>
      <Segment SegmentId="PER"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
    </Loop>
    <Loop LoopId="2100F">
      <Name>CUSTODIAL PARENT</Name>
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        <EntityIdentifier Code="S3"/>
      </StartingSegment>
      <Segment SegmentId="PER"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
    </Loop>
    <Loop LoopId="2100G">
      <Name>RESPONSIBLE PERSON</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="E1"/>
        <EntityIdentifier Code="EI"/>
        <EntityIdentifier Code="EXS"/>
        <EntityIdentifier Code="GD"/>
        <EntityIdentifier Code="J6"/>
        <EntityIdentifier Code="QD"/>
      </StartingSegment>
      <Segment SegmentId="PER"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
    </Loop>
    <Loop LoopId="2200">
      <Name>DISABILITY INFORMATION</Name>
      <StartingSegment SegmentId="DSB">
      </StartingSegment>
      <Segment SegmentId="DTP"/>
    </Loop>
    <Loop LoopId="2300">
      <Name>HEALTH COVERAGE</Name>
      <StartingSegment SegmentId="HD" />
      <Segment SegmentId="DTP"/>
      <Segment SegmentId="AMT"/>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="IDC"/>
      <Loop LoopId="2310">
        <Name>PROVIDER INFORMATION</Name>
        <StartingSegment SegmentId="LX"/>
        <Segment SegmentId="NM1"/>
        <Segment SegmentId="N1"/>
        <Segment SegmentId="N2"/>
        <Segment SegmentId="N3"/>
        <Segment SegmentId="N4"/>
        <Segment SegmentId="PER"/>
        <Segment SegmentId="PRV"/>
        <Segment SegmentId="DTP"/>
        <Segment SegmentId="PLA"/>
      </Loop>
      <Loop LoopId="2320">
        <Name>COORDINATION OF BENEFITS</Name>
        <StartingSegment SegmentId="COB"/>
        <Segment SegmentId="REF"/>
        <Segment SegmentId="N1"/>
        <Segment SegmentId="N2"/>
        <Segment SegmentId="N3"/>
        <Segment SegmentId="N4"/>
        <Segment SegmentId="DTP"/>
      </Loop>
    </Loop>
    <Loop LoopId="2400">
      <Name>LIFE COVERAGE</Name>
      <StartingSegment SegmentId="LC"/>
      <Segment SegmentId="AMT"/>
      <Segment SegmentId="DTP"/>
      <Segment SegmentId="REF"/>
      <Loop LoopId="2410">
        <Name>BENEFICIARY OR OWNER INFORMATION</Name>
        <StartingSegment SegmentId="BEN"/>
        <Segment SegmentId="NM1"/>
        <Segment SegmentId="N1"/>
        <Segment SegmentId="N2"/>
        <Segment SegmentId="N3"/>
        <Segment SegmentId="N4"/>
        <Segment SegmentId="DMG"/>
      </Loop>
    </Loop>
    <Loop LoopId="2500">
      <Name>FLEXIBLE SPENDING ACCOUNT</Name>
      <StartingSegment SegmentId="FSA"/>
      <Segment SegmentId="AMT"/>
      <Segment SegmentId="DTP"/>
      <Segment SegmentId="REF"/>
    </Loop>
    <Loop LoopId="2600">
      <Name>RETIREMENT PRODUCT</Name>
      <StartingSegment SegmentId="RP"/>
      <Segment SegmentId="DTP"/>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="INV"/>
      <Segment SegmentId="AMT"/>
      <Segment SegmentId="QTY"/>
      <Segment SegmentId="K3"/>
      <Segment SegmentId="REL"/>
      <Loop LoopId="2610">
        <Name>INDIVIDUAL OR ORGANIZATION NAME</Name>
        <StartingSegment SegmentId="NM1">
          <EntityIdentifier Code=""/>
        </StartingSegment>
        <Segment SegmentId="N2"/>
        <Segment SegmentId="DMG"/>
        <Segment SegmentId="BEN"/>
        <Segment SegmentId="REF"/>
        <Loop LoopId="2620">
          <Name>PROPERTY OR ENTITY IDENTIFICATION</Name>
          <StartingSegment SegmentId="NX1">
          </StartingSegment>
          <Segment SegmentId="N3"/>
          <Segment SegmentId="N4"/>
          <Segment SegmentId="DTP"/>
        </Loop>
      </Loop>
      <Loop LoopId="2630">
        <Name>FINANCIAL CONTRIBUTION</Name>
        <StartingSegment SegmentId="FC" />
        <Segment SegmentId="DTP"/>
        <Loop LoopId="2640">
          <Name>INVESTMENT VEHICLE SELECTION</Name>
          <StartingSegment SegmentId="INV"/>
          <Segment SegmentId="DTP"/>
          <Segment SegmentId="QTY"/>
          <Segment SegmentId="ENT"/>
          <Segment SegmentId="REF"/>
          <Segment SegmentId="AMT"/>
          <Segment SegmentId="K3"/>
        </Loop>
      </Loop>
      <Loop LoopId="2650">
        <Name>INCOME</Name>
        <StartingSegment SegmentId="AIN"/>
        <Segment SegmentId="QTY"/>
        <Segment SegmentId="DTP"/>
      </Loop>
    </Loop>
  </Loop>
</TransactionSpecification>

